Light aircraft accidents in the general aviation's leisure or training sector rarely teach the industry new lessons. The recently published report of a fatal accident in the UK, however, reminds the system of its duty of care to those new to the aviator's profession, and it proved again the truth of the oft-used adage that "aviation in itself is not inherently dangerous, but to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity or neglect".
Those three words can sound terribly unforgiving in themselves to those who feel keenly that they are being judged after an accident, but they are not absolutes.
Carelessness can be the result of a person judging that special care is not required under benign-looking circumstances. Incapacity can be the result of an unexpected situation that escalates beyond the capability of the person or people involved.
Neglect is the least forgiving of the three words but even that has degrees, ranging from a failure to recognise danger to a decision to take an unjustified risk.
The poignancy of the death of a very young aviator on his second solo flight who was unknowingly put into a situation outside his experience makes the UK Air Accidents Investigation Branch's report of this accident a very sad document, but also a must-read for everyone at the front line of flying operations, whether pilots, instructors or air traffic controllers.
It is a perfect example of Prof James Reason's model of how a multi-layer safety system can still be breached by an unfortunate combination of chances. In this event, the most cruel chance among several is a change of tower controllers in the few minutes between the time the solo student pilot called for taxi clearance and his arrival at the runway holding point.
The outgoing controller had two alerts to the fact that a very new aviator was about to get airborne for three circuits, but the message about the pilot's lack of experience did not get through to the relief controller.
When the relief controller faced an emerging decision about traffic priorities, he asked the student, then on short final to land, to go around again, adding a second instruction to "turn north". The pilot became confused and lost control of the aircraft.
If the same pilot had only a few more hours of experience the manoeuvre would not have been a problem for him. No words can comfort the parents of this 16- year-old pilot, but what about how the controllers feel? Another adage applies: there but for the grace of God go all of us. Read the report.
The report is a reminder of aviation's duty to new pilots
The report of this accident is a very sad document, but also a must-read for everyone.
Source: Flight International
